Procedural specialties

[Calizboosted76]

Whats up guys/gals,

I have been doing a lot of research trying to decide on a few more electives that I should choose for fourth year. Im going to be applying surgery or IM -> fellowship unless I come across a specialty that absolutely draws me in. Which is what brought me here.

Aside from the obvious specialties (Cards, GI, PCCM), what other procedural heavy specialties should I check out? I looked through SDN and Reddit and seen specialties like interventional spine as PMR which sparked my curiosity of other specialties that have a high frequency of doing procedures.

Im doing my surgery rotation right now and while doing choles, sleeves, ventral hernias is cool and all it lacks the excitement needed for me to deal with a surgical residency and do these surgeries for the rest of my life. I know I could always look into fellowships after surgery and I am considering that but Im curious what my options are for non-surgical procedure heavy specialties.

As always, that you all for the help!

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[Cornfed101]

You should do a pain rotation. Very procedure heavy, but somewhat less invasive. Maybe that’s more what you’re looking for

 

[Calizboosted76]

You should do a pain rotation. Very procedure heavy, but somewhat less invasive. Maybe that’s more what you’re looking for

I am definitely considering it. However something else I should have mentioned is that I enjoy resuscitation and running codes. On IM one of the most enjoyable and fulfilling parts were running to help with a code. I am not sure if pain will give me that adrenaline rush that I feel like I would benefit patients most with.

 

[Angus Avagadro]

Anesthesia. Lots of procedures. Airway management, invasive monitoring, US guided nerve blocks,regional anesthesia, Lumbar drains, Pain Management, TEE,CCM, and nobody calls a the code team to the OR. We are the code team. Just sayin'.

 

[Calizboosted76]

Anesthesia. Lots of procedures. Airway management, invasive monitoring, US guided nerve blocks,regional anesthesia, Lumbar drains, Pain Management, TEE,CCM, and nobody calls a the code team to the OR. We are the code team. Just sayin'.

So hear me out, I have tried and tried making myself want to pursue GAS but I do not think I would be happy in the OR and not be the one actively doing the surgery. I know it may sound silly.

This is a reason Im going to check out PCCM, still get to intubate, run codes, etc.

 

[Angus Avagadro]

No worries, all valid reasons. Choose the specialty where you see yourself on a daily basis and you find the literature stimulating. I never wanted to hold the scalpel and went into anesthesia to pursue CCM but found the burnout rate undesirable. Always something more to do and give. I would rather have my fingernails pulled out than have to do an IM residency before getting to do PCCM. I have had quite a varied career in anesthesia with a couple subspecialties, so it worked well for me.

 

[Calizboosted76]

No worries, all valid reasons. Choose the specialty where you see yourself on a daily basis and you find the literature stimulating. I never wanted to hold the scalpel and went into anesthesia to pursue CCM but found the burnout rate undesirable. Always something more to do and give. I would rather have my fingernails pulled out than have to do an IM residency before getting to do PCCM. I have had quite a varied career in anesthesia with a couple subspecialties, so it worked well for me.

Yea the only reason that I am considering the IM to PCCM route is because I actually enjoy being in the hospital and rounding from my inpatient IM rotation. The schedule isnt bad either. I have a 4 year old and she has definitely felt the impact of me going to medical school and she has been missing me more and more lately. So doing a week on and week off with the ability to open a few low SES clinics around my area (id be doing admin work there on off week) seems like a solid career choice. I just dont know if the adrenaline I am looking for will be there in strictly hospitalist med so PCCM seems to be a viable option unless I find something I enjoy more during electives.

 

[DO2015CA]

Adrenaline chasing does wane as you get older and settle into your career is what I’m told.

 

[Calizboosted76]

Adrenaline chasing does wane as you get older and settle into your career is what I’m told.

Thats what I keep hearing. However this is just the current wants I have. Which is another reason why maybe PCCM is the way that way as I get older I can transition to outpatient or Admin work.

 

[AlteredScale]

Interventional radiology, vascular neurology, PMR>interventional pain, ObGyn, ID or neph or hepatology/Critical Care.

Or be a hospitalist at a very small hospital, you'll do a ton of procedures.

Surgery hours suck. GI hours are much better and number of procedures are expanding rapidly especially in advanced and third space endoscopy (ESD/EMR, TORe, cTIFF, EUS cholecystogastrostomy, etc) . EGD/colons have enough variation with anatomy that being a general GI at a large academic center is really never boring.

 

[Calizboosted76]

Interventional radiology, vascular neurology, PMR>interventional pain, ObGyn, ID or neph or hepatology/Critical Care.

Or be a hospitalist at a very small hospital, you'll do a ton of procedures.

Surgery hours suck. GI hours are much better and number of procedures are expanding rapidly especially in advanced and third space endoscopy (ESD/EMR, TORe, cTIFF, EUS cholecystogastrostomy, etc) . EGD/colons have enough variation with anatomy that being a general GI at a large academic center is really never boring.

Awesome, I will put some of these on my list. My fear of doing hospitalist medicine is the midlevel scope creep. The other day a PA student was like "Oh Im going to be a hospitalist so technically I will be the same as you if you choose IM and work in a hospital". I about spit my drink out. However it got me thinking that if midlevels are able to do the exact same work, this will drive future compensation down the drain so.

 

[AlteredScale]

Most midlevels in hospital medicine aren't jumping to these smaller places. They want to be in bigger cities, have good hours, and decent PA. Smaller hospitals usually have open ICU's so you will do those procedures and do okay with that. But yes, midlevels will continues to expand hospitals will either make the choice to pay less with increased risk to the patient or bite the bullet and have a normal MD/DO there.

 

[Ho0v-man]

Awesome, I will put some of these on my list. My fear of doing hospitalist medicine is the midlevel scope creep. The other day a PA student was like "Oh Im going to be a hospitalist so technically I will be the same as you if you choose IM and work in a hospital". I about spit my drink out. However it got me thinking that if midlevels are able to do the exact same work, this will drive future compensation down the drain so.

This shouldn’t be a concern. NPP “hospitalists” aren’t good. They typically consult for everything under the sun, order tons of testing that doesn’t get reimbursed, then consult some more so someone will interpret the tests for them and then still never discharge the patient.

They’re useful in the real world for following up on time consuming things that don’t require any intelligence at all and copy pasting the last note into todays note on stable patients waiting for placement.

They might be better than you initially because they’ve admitted the same uncomplicated things 100 times, but you’ll blow past them by the end of intern year.

 

[Neopolymath]

Choosing based on adrenaline is a terrible idea. Basically nothing in medicine should be giving you adrenaline after you get good at it. There are very few situations this might happen and those situations are not situations good physicians find themselves in frequently.

Also, codes are boring and relatively algorithmic in the end.

 

[AlteredScale]

Choosing based on adrenaline is a terrible idea. Basically nothing in medicine should be giving you adrenaline after you get good at it. There are very few situations this might happen and those situations are not situations good physicians find themselves in frequently.

Also, codes are boring and relatively algorithmic in the end.

The bolded is so so true. Being in GI if you are getting nervous its because you encountered something new that you weren't prepared for or had experience with, you messed up, or you're an advanced endoscopist.

 

[Calizboosted76]

Choosing based on adrenaline is a terrible idea. Basically nothing in medicine should be giving you adrenaline after you get good at it. There are very few situations this might happen and those situations are not situations good physicians find themselves in frequently.

Also, codes are boring and relatively algorithmic in the end.

That makes sense. I also don’t want to choose solely based on adrenaline. I like high acuity and don’t rattle easily. In disaster type situations I am very good at polarizing a team. I enjoyed watching the ED docs I scribed for take a terrible situation like an acute MI and managing it. Or the CC doc getting to an actively coding patient and doing their thing.

Idk. I definitely want something where I can make an acute difference in peoples lives.

 

[Calizboosted76]

As a side note, I think I have to choose 5 specialties to explore. So far I am thinking about doing rotations in PCCM, Interventional Neurology, surgical oncology, interventional pain, maybe interventional radiology. Any other heavily procedural specialties that are not cards/GI

 

[DOVinciRobot]

Adrenaline chasing does wane as you get older and settle into your career is what I’m told.

Or about halfway through surgery residency lol

All I want a nice day of scheduled gallbags and hernias these days. Big cases on sick patients gets old fast.

OP sounds like you should look into trauma or vascular as surgery fellowships. Trauma has a lot of variety between cases, procedures, and managing ICU patients. Vascular is heavy on crunching endovascular procedures but you also do the big open bypass cases, lots of ways to fix the same problem and you’ll need to decide on the fly which intervention will be best.

 

[Calizboosted76]

Or about halfway through surgery residency lol

All I want a nice day of scheduled gallbags and hernias these days. Big cases on sick patients gets old fast.

OP sounds like you should look into trauma or vascular as surgery fellowships. Trauma has a lot of variety between cases, procedures, and managing ICU patients. Vascular is heavy on crunching endovascular procedures but you also do the big open bypass cases, lots of ways to fix the same problem and you’ll need to decide on the fly which intervention will be best.

Ive considered trauma. Thats what I thought I was going to have to do. Vascular is not the vibe for me lmfao. The vascular guy at our facility that Im rotating at works more than anyone I have ever seen in my life.

 

[AlteredScale]

As a side note, I think I have to choose 5 specialties to explore. So far I am thinking about doing rotations in PCCM, Interventional Neurology, surgical oncology, interventional pain, maybe interventional radiology. Any other heavily procedural specialties that are not cards/GI

what's keeping you away from cards/gi?

 

[Calizboosted76]

what's keeping you away from cards/gi?

So GI I am not a huge fan of the pathology. It just isnt what I see myself doing for the rest of my life. Cards on the other hand I am more open to because I do enjoy the pathology. I guess a big issue is I like knowing something about everything which I know Ill get in IM but I dont know if I like the idea of hyper specializing into only one body system if that makes sense.

 

[Goro]

Whats up guys/gals,

I have been doing a lot of research trying to decide on a few more electives that I should choose for fourth year. Im going to be applying surgery or IM -> fellowship unless I come across a specialty that absolutely draws me in. Which is what brought me here.

Aside from the obvious specialties (Cards, GI, PCCM), what other procedural heavy specialties should I check out? I looked through SDN and Reddit and seen specialties like interventional spine as PMR which sparked my curiosity of other specialties that have a high frequency of doing procedures.

Im doing my surgery rotation right now and while doing choles, sleeves, ventral hernias is cool and all it lacks the excitement needed for me to deal with a surgical residency and do these surgeries for the rest of my life. I know I could always look into fellowships after surgery and I am considering that but Im curious what my options are for non-surgical procedure heavy specialties.

As always, that you all for the help!

Urology

 

[DOVinciRobot]

Vascular is not the vibe for me lmfao. The vascular guy at our facility that Im rotating at works more than anyone I have ever seen in my life.

Lol, thought I’d throw it out there. But you are correct, vascular is a special hell

 

[Calizboosted76]

Lol, thought I’d throw it out there. But you are correct, vascular is a special hell

I appreciate it! I should have mentioned I have a 4 year old and I want to be a part of their life 😂

 

[Angus Avagadro]

I appreciate it! I should have mentioned I have a 4 year old and I want to be a part of their life 😂

Just a caveat, anything procedural that requires call weighs heavily on time off and a regular schedule.. Off hours, sleep deficits to replenish, days extended from patients getting sick as you are trying to leave, etc.. There is always something to do in CCM. You can't turn over an ICU procedure to your relieving Doc in the middle of it. There could be simultaneous arrests or near arrests and you can't leave. Interventional specialties aren't lifestyle specialties. Anyhow, good luck with your search and best wishes!

 

[Calizboosted76]

Just a caveat, anything procedural that requires call weighs heavily on time off and a regular schedule.. Off hours, sleep deficits to replenish, days extended from patients getting sick as you are trying to leave, etc.. There is always something to do in CCM. You can't turn over an ICU procedure to your relieving Doc in the middle of it. There could be simultaneous arrests or near arrests and you can't leave. Interventional specialties aren't lifestyle specialties. Anyhow, good luck with your search and best wishes!

Understood, I know that I will miss out on some things and that’s okay. I also realize that if I want something interventional or that I take call with that I will be at the hand of the hospital and my patients which is okay. The vascular guy I know though is working crazy hours.

With trauma surgery going towards a more 7on7off schedule I think this may be the way if I can’t find something Im more drawn to.

 

[FootballAndSkiing]

Just a caveat, anything procedural that requires call weighs heavily on time off and a regular schedule.. Off hours, sleep deficits to replenish, days extended from patients getting sick as you are trying to leave, etc.. There is always something to do in CCM. You can't turn over an ICU procedure to your relieving Doc in the middle of it. There could be simultaneous arrests or near arrests and you can't leave. Interventional specialties aren't lifestyle specialties. Anyhow, good luck with your search and best wishes!

except pain

 

[Calizboosted76]

except pain

Going to look more into this specialty for sure.

 

[Calizboosted76]

Sorry for all the questions everyone. I had been set on a specialty since I was a child but now that I am here Im starting to question if I want to be hyper-specialized or if I want to be more of a generalist that can also do procedures. I know I do not want to be a PCP. I also did not mind rounding on my inpatient IM rotation and from what I hear is you either hate it or love it.

Some things important to me are:
- Procedures (I would like interventions where I am doing something to help save the patients life but I am taking everyones advice into consideration with these getting old.)
- Pay (Would like to have the ability to gross $500K. I dont mind working and from what I have read this can be done as a hospitalist if you work a few extra days a month. So really this is a non issue.)
- Ability to be apart of private practice if I want. (Less important)
- Prestige (was super important to me but after being in the hospital and from what I can see, prestige and respect comes from how you practice.)

I am sure other things will become important to me as I age (currently 28 and my kid is 4). Time with my child is important to me however I feel that with most specialties as long as I am present during the time off I should be fine in that avenue but I am aware I dont know anything at this point of my career.

 

[DOVinciRobot]

Sorry for all the questions everyone. I had been set on a specialty since I was a child but now that I am here Im starting to question if I want to be hyper-specialized or if I want to be more of a generalist that can also do procedures. I know I do not want to be a PCP. I also did not mind rounding on my inpatient IM rotation and from what I hear is you either hate it or love it.

Some things important to me are:
- Procedures (I would like interventions where I am doing something to help save the patients life but I am taking everyones advice into consideration with these getting old.)
- Pay (Would like to have the ability to gross $500K. I dont mind working and from what I have read this can be done as a hospitalist if you work a few extra days a month. So really this is a non issue.)
- Ability to be apart of private practice if I want. (Less important)
- Prestige (was super important to me but after being in the hospital and from what I can see, prestige and respect comes from how you practice.)

I am sure other things will become important to me as I age (currently 28 and my kid is 4). Time with my child is important to me however I feel that with most specialties as long as I am present during the time off I should be fine in that avenue but I am aware I dont know anything at this point of my career.

Welcome to general surgery.

Residency is grueling, but life gets significantly better as an attending and you have much more control of your schedule. It also checks all of your criteria.

 

[lymphocyte]

Thats what I keep hearing. However this is just the current wants I have. Which is another reason why maybe PCCM is the way that way as I get older I can transition to outpatient or Admin work.

I used to think this too, and I've bailed out doing exactly what you describe: outpatient and admin work. But I really regretted going down the critical care path where it wrecked my health and sanity, especially during COVID.

The field is littered with so many burnouts (more than half, if recent surveys are to be believed). Many of them are in complete denial, and it ends up with terrible patient care and being a terrible colleague, not to mention personal misery.

I don't want to dissuade you from doing something you want to do. But I really recommend you don't commit 6 years of your life to something that makes you want to have a "backup" plan.

I'm surprised nobody's mentioned dermatology or PMR (apologies if they did, and I missed it!). Great hours, meaningful interventions, and very low burnout.

.https://www.medscape.com/slideshow/2021-lifestyle-burnout-6013456

 

[Angus Avagadro]

except pain

Possibly, but if you put in a narcotic pump or spinal cord stimulator, that patients is yours for life. Lots of calls and issues with refills and the stim probe migrating Sticking with steroid injections would be better for lifestyle.. Plus the partients are difficult due to drug seeking behavior . Not for me but lots of Docs do it.

 

[Calizboosted76]

I used to think this too, and I've bailed out doing exactly what you describe: outpatient and admin work. But I really regretted going down the critical care path where it wrecked my health and sanity, especially during COVID.

The field is littered with so many burnouts (more than half, if recent surveys are to be believed). Many of them are in complete denial, and it ends up with terrible patient care and being a terrible colleague, not to mention personal misery.

I don't want to dissuade you from doing something you want to do. But I really recommend you don't commit 6 years of your life to something that makes you want to have a "backup" plan.

I'm surprised nobody's mentioned dermatology or PMR (apologies if they did, and I missed it!). Great hours, meaningful interventions, and very low burnout.

.https://www.medscape.com/slideshow/2021-lifestyle-burnout-6013456

I really appreciate the response! As far as Derm and PMR go, I just don’t get excited in those fields. I feel like there is less acuity. I’m going to look into interventional pain and see if that sparks my interests but I don’t know that I want to deal with drug seeking behavior.

I have a meeting with the MED at my rotation site to get his input and suggestions on specialties to rotate in so I’m hoping he brings to like some unrealized (at least to me) specialty.

 

[Calizboosted76]

Welcome to general surgery.

Residency is grueling, but life gets significantly better as an attending and you have much more control of your schedule. It also checks all of your criteria.

This is what I am feeling too. I am going to do one more rotation in inpatient IM with an Open ICU and see if that scratches my procedural itch.

 

[FootballAndSkiing]

Possibly, but if you put in a narcotic pump or spinal cord stimulator, that patients is yours for life. Lots of calls and issues with refills and the stim probe migrating Sticking with steroid injections would be better for lifestyle.. Plus the partients are difficult due to drug seeking behavior . Not for me but lots of Docs do it.

The practice I rotated at refused to prescribe any drugs because it caused too many issues like the ones you listed. My understanding with SCS was that if its just a movement issue, that can be solved with the rep reprogramming it, if it was a bigger issue that would be solved by neuro surgery. They also didnt do narcotic pumps, but they the did say that would be the one true emergency in pain, specifically baclofen pumps.

 

[Royale with Cheese]

I know you said you didn't like the idea of playing second fiddle in the OR, but anesthesia checks all the boxes for you. Just have to figure out the ego thing of not being the actual surgeon.

Have you done an anesthesia rotation?

 

[Calizboosted76]

I know you said you didn't like the idea of playing second fiddle in the OR, but anesthesia checks all the boxes for you. Just have to figure out the ego thing of not being the actual surgeon.

Have you done an anesthesia rotation?

So I am unable to do anesthesia rotation unless I say that it is my number 1 choice and create my CV around it (per my core site director). I have a few friends in GAS and I have tried to get over the not being the surgeon in the OR but I havent figured out a way to do so lmfao.

 

[Royale with Cheese]

Well that's a sh**ty policy lol.

I'd highly recommend figuring out a way to squeeze in an anesthesia rotation before you completely write it off. Preferably before next summer when you need to get your residency app together.

I was in a similar boat thinking I would do something surgical. Ended up doing an anesthesia rotation at the end of 3rd year and immediately recognized it as the specialty for me.

 

[Calizboosted76]

Well that's a sh**ty policy lol.

I'd highly recommend figuring out a way to squeeze in an anesthesia rotation before you completely write it off. Preferably before next summer when you need to get your residency app together.

I was in a similar boat thinking I would do something surgical. Ended up doing an anesthesia rotation at the end of 3rd year and immediately recognized it as the specialty for me.

I will reach out to my CSC and try and figure a way to check it out! I appreciate the advice!

 

[GoBeers]

I will reach out to my CSC and try and figure a way to check it out! I appreciate the advice!

do GAS - > interventional pain.
you can play on both sides of the curtain when you feel like it
also, easy to spot "drug seekers" a mile away. you don't have to see them if you really don't want to by pre-screening them prior to consultation. many outpatient pain practices and even fellowships are opioid free now.

 

[DO2015CA]

So I am unable to do anesthesia rotation unless I say that it is my number 1 choice and create my CV around it (per my core site director). I have a few friends in GAS and I have tried to get over the not being the surgeon in the OR but I havent figured out a way to do so lmfao.

I think if you spend enough time in the OR, you’ll naturally get over being the surgeon. If you weren’t born to be a surgeon, it gets old fast. You quickly learn the anesthesia job is the sought after job in the OR. Much chiller job and you will earn your salt when the oh **** happens occasionally and you need to think quickly to intervene.

 

[dieABRdie]

As a side note, I think I have to choose 5 specialties to explore. So far I am thinking about doing rotations in PCCM, Interventional Neurology, surgical oncology, interventional pain, maybe interventional radiology. Any other heavily procedural specialties that are not cards/GI

ENT? Huge range of surgeries, procedures (lots can be outpatient to escape hospital admins), fairly safe from midlevels and there is tremendous need for general ENT in many areas, running codes is algorithmic and will get boring quick; but you might have the chance to do an emergent tracheostomy here and there?

That would definitely be on my list; and someone else said Urology, which has similar breadth/depth/moat.

 

[Calizboosted76]

ENT? Huge range of surgeries, procedures (lots can be outpatient to escape hospital admins), fairly safe from midlevels and there is tremendous need for general ENT in many areas, running codes is algorithmic and will get boring quick; but you might have the chance to do an emergent tracheostomy here and there?

That would definitely be on my list; and someone else said Urology, which has similar breadth/depth/moat.

ENT is definietly on my list! Uro Im not to fascinated by but I will bring it up at my meeting. I appreciate the suggestions!

 

[DOVinciRobot]

I think if you spend enough time in the OR, you’ll naturally get over being the surgeon. If you weren’t born to be a surgeon, it gets old fast. You quickly learn the anesthesia job is the sought after job in the OR. Much chiller job and you will earn your salt when the oh **** happens occasionally and you need to think quickly to intervene.

I have reported you for these blasphemous comments.

Surgery is the way. The only way.

Sorry, I'm bored on nights lol

 

[eyeeye_captain]

Both are pretty niche, but doing ophthalmology and then a retina or oculoplastics fellowship fits pretty well. Injections or laser for around 2/3 of my retina clinic patients, 3-10 surgeries a week, less than 40 hours a week, light call. Downsides are 6 years of training, competition, and some people getting creeped out by eyeballs.

General ophtho is same lifestyle with more surgery and fewer in office procedures.

 

[DO2015CA]

I have reported you for these blasphemous comments.

Surgery is the way. The only way.
View attachment 377396


Sorry, I'm bored on nights lol

Haha! Spoken like a true surgeon! As a proceduralist, I enjoy the OR for my 20-30
Min procedure and I’m out… still rather do them in the Endo suite though lol.

 

[whatsthepoint]

Interventional radiology, vascular neurology, PMR>interventional pain, ObGyn, ID or neph or hepatology/Critical Care.

Or be a hospitalist at a very small hospital, you'll do a ton of procedures.

Surgery hours suck. GI hours are much better and number of procedures are expanding rapidly especially in advanced and third space endoscopy (ESD/EMR, TORe, cTIFF, EUS cholecystogastrostomy, etc) . EGD/colons have enough variation with anatomy that being a general GI at a large academic center is really never boring.

what kind of procedures can a hospitalist at a small hospital do? sounds interesting

 

[DO2015CA]

what kind of procedures can a hospitalist at a small hospital do? sounds interesting

Central lines, chest tubes, intubations are standard